In the last 10 years, outpatient psychotropic prescribing to pediatric populations in the United States has ballooned, with the greatest increase seen in the use of atypical antipsychotics for off-label uses, such as the management of persistent aggressive behavior in children and adolescents (Martin and Leslie 2003
; Cooper et al. 2004
; Olfson et al. 2006
). At the same time, the use of psychosocial and psychological interventions has declined, raising significant concerns about the current overreliance on pharmacotherapy in the treatment of children and adolescents (Mojtabai and Olfson 2008
). In light of the gap between the research literature and clinical practice, the current survey findings suggest that expert consensus opinion can provide an alternative perspective and support the development of best practice guidelines for optimal outpatient management in children and adolescents with severe and persistent behavioral difficulties. The usefulness of expert consensus in developing treatment strategies for children and adolescents has been demonstrated in other psychiatry initiatives, such as Guidelines for Adolescent Depression in Primary Care (Cheung et al. 2007
) and Treatment Recommendations for the Use of Antipsychotics for Aggressive Youth (Pappadopulos et al. 2003
). High degrees of consensus among survey responders suggest that there is general agreement on optimal treatment strategies for pediatric aggression.
In contrast to current practice trends, the results of this survey show that experts strongly support the use of evidence-based psychosocial interventions (e.g., behavior therapy and parent management training vs. play therapy and art therapy) and parent education and training before the use of medication for maladaptive aggression—at every stage of medication treatment from diagnosis to maintenance to medication discontinuation. The fact that the primary or coutilization of psychosocial interventions is not consistently followed in clinical practice (Crystal et al. 2009
) can be due to a number of reasons, including lack of (quickly) available therapy appointments, scarcity of resources, urgency/severity of the problem, paucity of therapists using evidence-based psychotherapy methods, desire for a “quick fix,” and refusal to engage in nonpharmacologic treatments. Further, much of what was endorsed by experts appears to be consistent with the literature. For example, with regard to the use of polypharmacy for aggression, survey responders agreed that monotherapy is preferable to polypharmacy for most conditions, except for bipolar symptoms such as severe mood lability. These findings suggest that a systematic model for outpatient treatment of pediatric maladaptive aggression that is informed by the systematically derived expert opinion and the literature is attainable.
These survey findings provide consistent evidence of expert endorsement of strategies that emphasize the importance of behavioral interventions and talking to families about their treatment preferences. However, in routine clinical practice, such behavioral interventions are not often used (Mojtabai and Olfson 2008
; Crystal et al. 2009
), suggesting that they should be done more regularly and systematically.
Although clinicians endorsed the use of rating scales to assess target symptoms, experts supported the use of more general measures of child psychopathology such as the Child Behavior Checklist (CBCL), which may reflect familiarity rather than the usefulness of a more specific measure. Further, this finding may also reflect clinicians' needs to balance convenience and time constraints with the narrowness of any particular measure. Also of interest was that clinicians did not strongly endorse the use of measures of functioning or quality of life, even though this is the ultimate focus of treatment. Experts seem focused on the more immediate treatment issues and symptoms as opposed to the long-term impact on functioning and quality of life.
Experts also strongly endorsed intervention strategies to help build the therapeutic relationship. Such approaches can be easily taken for granted and cannot be replaced by treatment consent procedures that were not highly rated. Education and the use of written materials were strongly endorsed, although it is unclear how often patients and families actually receive handouts. Experts seemed aware of the constraints in busy practice settings and concentrated on interventions that would not be too time consuming or otherwise unrealistic because of excessive burdens on clinicians.
The use of psychosocial interventions at every phase of treatment was strongly endorsed by clinicians and never considered inappropriate. Yet, Mojtabai and Olfson (2008
) have shown that the use of psychosocial interventions has been significantly curtailed in child and adolescent psychiatric care. Although behavior therapy was rated highly and is strongly supported by the literature (Scotto Rosato et al., submitted), environmental interventions and parent education were more strongly supported than group interventions for the child, such as anger management and social skills training.
In terms of pharmacological interventions, experts supported the use of medication for patients with high risk for interpersonal harm or psychosis. Additionally, ratings of other items indicate that, generally, expert opinion does not support the use of medications for difficult children to address symptoms that are limited to minor aggression, such as persistent cursing, mild temper outbursts, or stealing. Expert ratings did support pharmacological interventions that focus on the underlying symptoms or primary diagnosis rather than chasing symptoms. The importance of evaluating and treating co-morbid symptoms was also strongly endorsed.
Experts endorsed the use of atypical antipsychotics and mood stabilizers as first-line strategies for treating clinically significant aggression. Interestingly, levels of expert support for use of atypical antipsychotics and use of mood stabilizers were similar. Unfortunately, however, to date, studies are lacking that could provide support for choosing one class of agents over another. Moreover, comparative effectiveness evidence is missing, which would provide information about the relative efficacy and safety of different agents, even within each medication class. When medication treatments were not working, experts strongly supported the assessment of patient compliance before changing the medication regimen. They noted the importance of only changing one medication at a time to fully realize the benefits or costs of any particular agent in the regimen. The use of within class polypharmacy was viewed with some degree of skepticism.
It is interesting that experts supported the use of a stimulant in cases of failed behavior therapy for conduct disorder. Although the initial use of stimulants in youth with behavioral problems and ADHD has been strongly endorsed before (Pliszka et al. 2006
), there appeared to be emerging consensus that stimulants may be appropriate even in the absence of clear-cut ADHD symptoms, most likely because they would offer the quickest response with the least potential for dangerous or unexpected side effects. This finding remains an important area for future investigation. Finally, experts were cautious about discontinuing successful pharmacotherapy in light of a history of persistent symptoms or relapse during discontinuation. Although doctors emphasized the importance of preventing another relapse during adherence with a given medication, life-threatening side effects such as neutropenia and a marked increase in LFTs were also justifications for change. It is important to note that fasting glucose abnormalities and significant weight gain were also first-line reasons to switch medications along with persistent sedation, abnormal ANC (absolute neutrophil count), and ECG (electrocardiogram) changes. Respondents rated gynecomastia in boys/men and sexual dysfunction in teens relatively less important within the context of the treatment options presented in the question on switching. Such items may not be as critical to clinicians who are trying to manage very serious and at times dangerous aggressive symptoms; however, these very items may be critical to child and adolescent adherence with their antipsychotic treatment regimen. In contrast, consistent with current recommendations for the monitoring and management of antipsychotic-treated youth (Correll 2008
), isolated prolactin elevations had the lowest justification for switching antipsychotics.